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CHILDREN’S SERVICES HANDBOOK APPENDIX A: THSTEPS FORMS A.1 Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-296 A.2 Child Health Clinical Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-296 A.3 Guidelines for Tuberculosis Skin Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-297 A.4 Laboratory Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-297 CH.37 Child Health History (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-298 CH.38 Child Health Record (Birth–1 Month) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-300 CH.39 Child Health Record (2–6 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-302 CH.40 Child Health Record (7–12 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-304 CH.41 Child Health Record (13 Months–2 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-306 CH.42 Child Health Record (3–5 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-308 CH.43 Child Health Record (6-10 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-310 CH.44 Hearing Checklist for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-312 CH.45 Hearing Checklist for Parents (Spanish). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-313 CH.46 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) . . . . . . . . . . . . . . . . . . . . . . . . CH-314 CH.47 Mental Health Interview Tool/Referral Form (Ages 3–9 Years) . . . . . . . . . . . . . . . . . . . . . . . . CH-315 CH.48 Mental Health Interview Tool/Referral Form (Ages 10–12 Years). . . . . . . . . . . . . . . . . . . . . . CH-316 CH.49 Mental Health Interview Tool/Referral Form (Ages 13–20 Years). . . . . . . . . . . . . . . . . . . . . . CH-317 CH.50 Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages) . . . . . . . . . . . . . . . . . . CH-318 CH.51 Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) . . . . . . . . . . . . . . . . CH-320 CH.52 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . CH-322 CH.53 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish) . . . . . . . . . . . . CH-324 CH.54 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . CH-326 CH.55 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish) . . . . . . . . . . CH-328 CH.56 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . CH-330 CH.57 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish) . . . . . . . . . . CH-332 CH.58 Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages) . . . . CH-334 A.5 Tuberculosis Screening and Education Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-336 CH.59 TB Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-337 CH.60 Cuestionario Para la Detección de Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-338 CH.61 How to Determine TB Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-339 CH.62 PPD Agreement for Texas Health Steps Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-340 CH.63 TVFC Patient Eligibility Screening Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-341 CH.64 TVFC Patient Eligibility Screening Record (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-342 CH.65 TVFC Provider Enrollment (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-343 CH.66 TVFC Questions and Answers (3 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH-346 CH-295 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 A.1 Claim Forms Providers must order CMS-1500 and ADA Dental Claims Forms from the vendor of their choice. Copies cannot be used. Claims filing instructions and examples of the claim forms are located in Section 6: Claims Filing (Vol. 1, General Information). Refer to: Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Subsection 6.5.3, “CMS-1500 Blank Paper Claim Form” in Section 6, “Claims Filing” (Vol. 1, General Information). Subsection 6.7, “2006 American Dental Association (ADA) Dental Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). A.2 Child Health Clinical Records The use of forms ECH 1–7 is optional. These forms were developed to help providers document all components of the medical checkup. THSteps requires the following forms: Hearing Checklist for Parents, Tuberculosis (TB) Questionnaire, Risk Assessment for Lead Exposure, and the DSHS State Laboratory forms. All of these forms can be downloaded from the THSteps website at http://dshs.state.tx.us/thsteps/forms.shtm. Lead poisoning screening questionnaires can be downloaded from the Texas Childhood Lead Poisoning Prevention Program (TX CLPPP) website at www.dshs.state.tx.us/lead/providers.shtm. Forms CH-9W through CH-12W may be downloaded from the Centers for Disease Control and Prevention (CDC) website at www.cdc.gov/growthcharts/clinical_charts.htm. Stock Number Form CH-9W Growth Chart - Infant Girl CH-10W Growth Chart - Infant Boy CH-11W Growth Chart - Child Girl CH-12W Growth Chart - Child Boy ECH-1 Child Health History ECH-2 Preventive Health Visit - Birth to 1 Month ECH-3 Preventive Health Visit - 2–6 Months ECH-4 Preventive Health Visit - 7–12 Months ECH-5 Preventive Health Visit - 13 Months to 2 Years ECH-6 Preventive Health Visit - 3–5 Years ECH-7 Preventive Health Visit - 6–10 Years Form Pb-110, Risk Assessment for Lead Exposure TB Questionnaire For forms for documenting medical checkups for adolescents, please refer to sources such as Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (2nd edition, revised), located at www.brightfutures.org or the Guidelines for Adolescent Preventive Services (GAP) Implementation Materials located at www.ama-assn.org/ama/pub/category/1981.html. For nutritional screening for all ages, refer to Bright Futures. CH-296 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK A.3 Guidelines for Tuberculosis Skin Testing For information on procedures for tuberculosis skin testing, refer to the Department of State Health Services (DSHS) tuberculosis web page at www.dshs.state.tx.us/idcu/disease/tb/. Tuberculosis screening questionnaires can be downloaded from the Tuberculosis Elimination Division website at www.dshs.state.tx.us/idcu/disease/tb/forms/default.asp#clinic. A.4 Laboratory Forms For information on procedures for submission of laboratory forms, refer to the DSHS Laboratory Services Section’s web page at www.dshs.state.tx.us/lab/MRS_forms.shtm. CH-297 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.37 Child Health History (2 Pages) Child Health History Department of State Health Services Child Health Record Preventive Health Visit Pregnancy and Birth G ___ P ___ AB ____ Total number of living children ________Weight gain/loss__________ Mother’s age at birth ________________ Number of years between previous pregnancy and this child _______ Trimester Prenatal Care Began: 1 2 3 Prenatal Care Provider _______________________________________ Vitamins: ____Y __ N Iron: ____Y __ N If child over 5 years: uncomplicated pregnancy, labor, delivery and nursery course:___ Y____N* *If yes, proceed with “Child’s Medical History. Maternal Complications ____Vaginal bleeding ____Anemia ____Hypertension ____Rh negative ____Diabetes ____Premature labor ____Injury/hospitalization/surgery ____Flu-like illness or high temp. ____Kidney or bladder infection ____STDs ____Hepatitis (A, B, or C) ____Exposure to TB ____Exposure to lead/chemicals ____Dental disease Maternal Substance Use ____OTC meds _____________________________________________ ____Prescription meds ______________________________________ ____Tobacco ______________________________________________ ____Alcohol ______________________________________________ ____Street drugs ___________________________________________ ____Caffeine ______________________________________________ Abbreviations for relatives listed below. ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Anemia//blood disorder Heart disease before age 50 Cholesterol req. treatment Hypertension/stroke Asthma/allergy Cancer Diabetes Epilepsy/seizures Kidney problems Muscle/bone disease Genetic disease or major birth defects ____ Childhood hearing impairment ____ Tuberculosis Explanation of positive history: Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________ Birth/Delivery Place of birth ______________________________________________ Birth attendant _____________________________________________ Hours of labor______________________________________________ ____Term ____Premature (Weeks)________ ____More than 2 weeks overdue Type of delivery: PGM PGF PA PU - Paternal Grandmother Paternal Grandfather Paternal Aunt Paternal Uncle Y N HIV + individual in household (do not identify) ____ Other immunosuppression ____ Dental decay ____ Alcohol/drug abuse ____ Tobacco use ____ Learning disorder ____ Mental retardation ____ Psychiatric disorder ____ Physical/sexual/emotional abuse ____ Domestic violence ____ Other Complications: ____Breech ____Multiple birth ____Other ____Vaginal ____C-Section ____Forceps Explanation/Other: Nursery Course Birth Weight _________ Birth Length ________ FOC _________ ____Difficulty with initial breathing ____Transfusion ____Heart murmur ____Jaundice req. treatment ____Infection ____Seizures Age at discharge: _________ICN ____________ days Newborn blood screening (date/location): 1. ________________________________________________________ 2. ________________________________________________________ ____ Normal ______ Abnormal Newborn hearing test (in hospital): Type of test: ____ ABR Referral made: ____Y Comments: Family Medical History M - Mother MGM - Maternal Grandmother F - Father MGF - Maternal Grandfather S - Sibling MA - Maternal Aunt MU - Maternal Uncle Client Information ____OAE ____N ____Unknown Child’s Medical History Immunizations current: ___Y ___N Dental care/sealants current: ___Y ___N ____Trauma/injuries ____Hospitalizations ____Surgery ____Medications ____Anemia ____Early childhood caries ____Hepatitis ____Strep throat ____Ear infections ____Bladder/kidney infections ____Pneumonia ____Developmental delays __ Record unavailable ____Vision problems ____Hearing problems ____Seizures ____Environmental toxin exposure (lead, etc.) ____Allergies ____Asthma ____Eczema ____Substance use (alcohol, drug, tobacco) ____Other Explanation: Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________ CH-298 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK Child Health History If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-1 CH-299 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Rev. 9/07 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.38 Child Health Record (Birth–1 Month) (2 Pages) Birth–1 Month Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health Child lives with: ____ Father Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________ Nutrition _____ No change in household since last visit _____ Mother _____ Other Client Information ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home: ____________________________ Primary caretaker for this child:__________________________ Relationship: _________________________________________ Family’s concerns/problems: Problems: developmental, special diet, inappropriate weight gain/loss, chronic GI problems* _____ Y _____ N *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ Length of feedings: _________________ WIC: _____ Y _____ N Formula-fed: Type:__________________________________________ Iron fortified: _____ Y _____ N Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Solid foods introduced at age: Development Sensory Parent’s concerns: Developmental Screening: _____P ____ F Type of Developmental Screen: Standardized Parent Questionnaire: _____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side): Child’s Health Allergies: Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (state when and describe): Vision Screen: Hearing Screen: Screen used: _____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents Health Education Injury Prevention Health Promotion ___Car safety restraints ___Crib safety ___Burns ___Falls ___Drowning/bath safety ___911 ___Sleep position (SIDS) ___Passive smoking ___Care of skin, umbilical cord, circumcision ___Family planning ___Well-child care ___When to call doctor Behavior Medications taken regularly — Type/Reason: ___Crying/colic ___Sleeping ___Infant temperature Physical Examination Assessment Nutrition ___Breastfeeding ___No solids until 4 months ___Formula preparation ___Infant held for bottle ___No bottle in bed Temp _________ Pulse ____________Resp ____________ FOC__________ Height ___________Weight ___________ (%) ___________ (%) ______________(%) ______________ N ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ A NE ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes (RR) ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts Additional documentation: N ___ ___ ___ ___ ___ ___ A NE ___ ___ ___ ___ ___ ___ ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities Plan Neurologic: ___ ___ ___ Muscle tone ___ ___ ___ DTRs ___ ___ ___ Primitive reflexes WIC: __ Referred __ Refused __ N/A Immunizations: __ Up to date __ To be given today __ Deferred Explain: Lab: Newborn Screening: _____ Up to date ____ To be done today Next appointment: Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________ CH-300 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK Birth–1 Month If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Rashes, infections, jaundice, cyanosis Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal: Eyes: Eye discharge, excessive tearing Nose/Mouth/Throat: Nasal congestion History of murmur, trouble with breathing, wheezing Bowel movement frequency, problems/concerns, vomiting (Male) Normal stream, circumcision, number of wet diapers Seizures, sucking reflex, swallowing Range of motion Mental Health The mental health assessment of this age also includes the developmental assessment and information from the family profile. Feelings: Behavior: Social Interaction: Thinking: Physical Problems: Other: Anxious, cries excessively or too little, irritable Overactivity, listlessness Failure to respond socially Unattentive Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-2 CH-301 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Rev. 1/07 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.39 Child Health Record (2–6 Months) (2 Pages) Client Information 2–6 Months Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health Nutrition _____ No change in household since last visit ____ Father developmental,special diet, inappropriate _____ Y _____ N weight gain/loss, chronic GI problems* *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ WIC: _____ Y _____ N Length of feedings: _________________ Formula-fed: Type: __________________________________________ _____ Y _____ N Iron fortified: Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Problems: Child lives with: _____ Mother _____ Other Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________ ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________ Family’s concerns/problems: Solid foods introduced at age: Development Sensory Parent’s concerns: DevelopmentalScreening: _____P ____ F Vision Screen: Hearing Screen: Screen used: Type of Developmental Screen: Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ _____Y ____ N Further assessment needed: Mental Health (see “Key Elements” on reverse side): Child’s Health/Interim History Allergies: Does the system review note any problems _____ Y _____ N or parent concerns: Explain: Major illness, injury, hospitalization,surgery (since last visit): _____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents Health Education Injury Prevention Health Promotion ____Car safety restraints ____Falls, Infant walker ____Burns ____Choking management ____Sleep position (SIDS) ____Passive smoking ____Pool/bath safety ____Immunizations ____Thermometer use, Tylenol ____Teething, wipe teeth ____When to call doctor ____Well-child care ____Family planning Behavior ____Breastfeeding ____No solids until 4 months ____Formula preparation ____Infant held (no bottlein bed) Medications taken regularly —Type/Reason: ____Parent/infant interaction ____Sleeping ____Inappropriate expectations ____Daycare/babysitters Physical Examination Assessment Nutrition Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%)___________ (%) ______________(%)______________ N A ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ __ __ __ __ __ __ __ __ __ __ NE ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes (RR) ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts Additional documentation: N A ____ ____ ____ ____ ____ ____ __ __ __ __ __ __ NE ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities Plan Neurologic: ____ __ ___ Muscle tone ____ __ ___ DTRs ____ __ ___ Primitive reflexes Dental Referral ____ ____ Referred ___ N/A ____ Refused WIC: To be given today ___ Deferred Immunizations: Up to date Explain: Lab: Hct/Hgb ______ Lead questionnaire (at 6 months) ______ Newborn Screening: Up to date ____ To be done today Next appontment: Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________ CH-302 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK 2–6 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Ears: Rashes, infections Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal: Eyes: Eye discharge, deviation, excessive tearing Nose/Mouth/Throat: Nasal congestion History of murmur, trouble with breathing, wheezing Bowel movementfrequency, problems/concerns, vomiting (Male) Normal stream, number of wet diapers Seizures, coordinated movements Fractures, range of motion Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Anxious, cries excessively or too little,irritable Behavior: Overactivity,listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-3 Rev. 01/2011 CH-303 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.40 Child Health Record (7–12 Months) (2 Pages) Client Information 7–12 Months Department of State Health Services Child Health Record Preventive Health Visit Family Profile and Health Nutrition _____ No change in household since last visit Child lives with: _____ Mother _____ Other ____ Father Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________ ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child: __________________________ Relationship: _________________________________________ Family’s concerns/problems: Problems: developmental, special diet, inappropriate weight gain/loss, chronic GI problems* _____ Y _____ N *If answered yes, further assessment needed. Breast-fed: Number of feedings in last 24 hours: _________________ Length of feedings: _________________ WIC: _____ Y _____ N Formula-fed: Type: __________________________________________ Iron fortified: _____ Y _____ N Ounces consumed in 24 hours: _______ Fluoride: _____ Y _____ N Solid foods introduced at age: Development Sensory Parent’s concerns: Developmental Screening: _____P ____ F Type of Developmental Screen: Standardized Parent Questionnaire: _____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side): Child’s Health/Interim History Allergies: Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (since last visit): Medications taken regularly — Type/Reason: Physical Examination Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%) ___________ (%) ______________(%) ______________ N A ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ NE ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts Additional documentation: N A ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Vision Screen: Hearing Screen: Screen used: _____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents Health Education Injury Prevention Health Promotion ___Car safety restraints ___Falls (stairs, gates) ___Choking management ___Water safety/temp ___Poisoning ___Child proofing ___Passive smoking ___Immunizations ___Teething ___Cleaning teeth ___When to call doctor ___Well-child care ___Dental appointment ___Family planning Behavior Nutrition ___Parent/infant interaction, expectations ___Speech development ___Sleep ___Separation protest ___Daycare ___Breastfeeding support ___Introduction of solids ___No bottle in bed ___Off bottle by 1 year Assessment NE ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities Neurologic: ___ ___ ___ Muscle tone ___ ___ ___ DTRs Plan TB Risk Screen ing Tool (12 months): ___ Dental referral made: __ Y _ N WIC: __ Referred ___Refused __ N/A Immunizations: __ Up to date ___To be given today __ Deferred Explain: Lab: Newborn Screening: ___ Up to date ___To be done today Hct/Hgb _____Blood lead test (at 12 months) ________ Lead questionnaire (at 9 months) ___________ Next appointment: Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________ CH-304 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK 7–12 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Rashes, infections Eyes: Eye discharge, deviation, wandering eye movement Ears: Hearing or ear problems Nose/Mouth/Throat/Teeth: Nasal congestion Cardio/respiratory: History of murmur, trouble with breathing, wheezing Gastrointestinal: Bowel movement frequency, problems/concerns, vomiting Genitourinary: (Male) Normal stream Neuromuscular: Coordination Musculoskeletal: Fractures Mental Health The mental health assessment of this age also includes the developmental assessment and information from the family profile. Feelings: Anxious, cries excessively or too little, irritable Behavior: Overactivity, listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-4 CH-305 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Rev. 01/2011 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.41 Child Health Record (13 Months–2 Years) (2 Pages) Client Information 13 Months–2 Years Department of State Health Services Child Health Record Preventive Health Visit Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________ Family Pr Nutrition _____ No change in household since last visit Family’s concerns/problems: special diet, inappropriateweight gain, anemic, chronic GI problems, major food allergies, _____ Y _____ N refusal of any food group, developmental* *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy __ Formula ___Breast ___Vegetables WIC: ___ Y __ N ____Breads, cereal, rice, and pasta eggs, and dry beans ____Meat, poultry, ____Fruits Development Sensory Parent’s concerns: Vision Screen: Hearing Screen: Screen used: Problems: Child lives with: _____ Mother _____ Other ____ Father ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________ DevelopmentalScreening: _____P ____ F Type of Developmental Screen: Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ _____Y ____ N Further assessment needed: Mental Health (see “Key Elements” on reverse side): Child’s Health/Interim History Allergies: Does the system review note any problems _____ Y _____ N or parent concerns: Explain: Major illness, injury, hospitalization,surgery (since last visit): Medications taken regularly —Type/Reason: Dental Care: Physical Examination BMI (2 years) ______ Temp _________ Pulse ____________Resp ____________ FOC __________ Length ___________Weight___________ (%)___________ (%) ______________(%)______________ N ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ A NE __ __ __ __ __ __ __ __ __ __ ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat Teeth ___ Neck ___ Chest/breasts Additional documentation: N ____ ____ ____ ____ ____ ____ _____Normal _____ Abnormal _____Normal _____ Abnormal _____Hearing Checklist for Parents Health Education Injury Prevention ____Car safety restraints ____Choking, unsafe toys ____Poisoning ____Burns ____Water safety/temp ____Supervised play ____Electrical injury ____Passive smoking ____Sibling rivalry ____Toilet training Health Promotion ____Immunizations ____Smoking in home ____Well-child care ____Dental care, appointment ____Family planning ____Daycare Behavior Nutrition ____Parent/infant interaction ____Social interaction ____Limit TV ____Set limits ____Healthy diet/snacks ____Iron-rich foods ____Physical activity ____Weaning ____O bottleby age 1 Assessment A NE __ __ __ __ __ __ ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine/hips ___ Extremities Neurologic: ____ __ ___ Muscle tone ____ __ ___ DTRs Plan TB Risk Questionnaire (2 years) ______ Dental referral made: ___Y ___ N ____Referred ___ Refused ___ N/A WIC: Immunizations: ____Up to date ___ To be given today ___ Deferred Explain: Lab: Hct/Hgb ______ Blood lead test (at 2 years) __________ Lead questionnaire: (at 15 months) _____ and (at 18 months) _____ Next appointment: Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________ CH-306 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK 13 Months–2 Years If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Rashes, infections Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal: Eyes: Eye discharge, deviation, wandering eye movement Nose/Mouth/Throat/Teeth: Nasal congestion History of murmur, trouble with breathing, wheezing Bowel movementfrequency Urinary frequency, (male) normal stream, dysuria, discharge Seizures, coordination, gait Fractures Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Angry, sad, fearful, sullen, anxious, cries excessively or too little Behavior: Overactivity,listlessness, harms others, sexually acts out, refuses to talk Social Interaction: Withdrawn, clings excessively Thinking: Mistrustful, distracted, problems concentrating Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-5 CH-307 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Rev. 01/2011 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.42 Child Health Record (3–5 Years) (2 Pages) Client Information 3–5 Years Department of State Health Services Child Health Record Preventive Health Visit Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship:______________________________________ Medical Home: _____________________________________________ Family Profile and Health Nutrition _____ No change in household since last visit Problems: special diet, inappropriateweight gain, anemic, lead poisoning, chronic GI problems, major food allergies, refusal of any food group, developmental* _____ Y _____ N *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy __ Vegetables__ WIC: ___ Y __ N ____Breads, cereal, rice, and pasta Flouride Supplements: ___ Y __ N ____Meat, poultry, fish, eggs, and dry beans ____Fruits Vitamins: ___ Y __ N Child lives with: _____ Mother _____ Other ____ Father ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child:__________________________ Relationship:_________________________________________ Family’s concerns/problems: Development Sensory Parent’s concerns: DevelopmentalScreening: _____P ____ F Type of Developmental Screen: Standardized Parent Questionnaire:_____________________________ Standardized Observational Screen: ____________________________ Other: ____________________________________________________ Further assessment needed: _____Y ____ N Mental Health (see “Key Elements” on reverse side): Child’s Health/Interim History Allergies: Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization,surgery (since last visit): Dental Care: Physical Examination BMI__________ Temp _________ Pulse ____________Resp ____________ BP ___________ Height ___________Weight___________ (%)___________ (%) ______________(%)______________ N A NE __ __ __ __ __ __ __ __ __ __ ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts Additional documentation: N ____ ____ ____ ____ ____ ____ Health Education Injury Prevention ____Car safety restraints ____Poisoning ____Fire safety ____Firearms ____Street, water, bicycle safety ____Scissors/sharp objects ____Stranger safety ____Teach telephone no. & address ____Self-safety ____Passive smoking Behavior Medications taken regularly —Type/Reason: ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Vision Screen: _____Normal ____ Abnormal Hearing Screen: _____Normal ____ Abnormal Hearing Screen Used (3 years): _____ Hearing Checklist for Parents ____Talk/read with child ____Exploration ____Limit television ____Discipline, consistency ____Toilet training ____Social interaction ____School readiness ____Sex education Health Promotion ____Immunizations ____Well-child care ____Dental care, appointment ____Family planning ____Daycare Nutrition ____Healthy diet/snacks ____Junk food ____Iron-rich foods ____Physical activity Assessment A NE __ __ __ __ __ __ ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus ___ Spine ___ Extremities Plan Neurologic: ____ __ ___ Muscle tone ____ __ ___ DTRs TB Risk Screening Tool: _____ Dental referral made: ___Y ___ N WIC: ____Referred ___ Refused ___ N/A Immunizations: ___Up to date ___ To be given today ___ Deferred Explain: Lab: Lead questionnaire: ______ Y _____ N Hct/Hgb ______ Next appointment: Date: ________________ Signature/Title: __________________________________ Signature/Title________________________________________ CH-308 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK 3–5 Years If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Rashes, infections Ears: Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal: Eyes: Eye discharge, blinking, tearing Nose/Mouth/Throat/Teeth: Nasal congestion History of murmur, trouble with breathing, wheezing Bowel movementfrequency, soiling Dysuria, discharge Seizures, coordination, gait Fractures Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Out of control, angry, sad, fearful, sullen, anxious Behavior: Overactive, listlessness, harms others or property, sexually acts out, impulsive, frequentlyprovokes other children, self-abuses Social Interaction: Withdrawn, clings excessively, acts too young, communicates non-verballyrather than verbally Thinking: Mistrustful, distracted, easily frustrated Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-6 CH-309 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Rev. 01/2011 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.43 Child Health Record (6-10 Years) (2 Pages) Client Information 6–10 Years Department of State Health Services Child Health Record Preventive Health Visit Name: ____________________________________________________ DOB: _______ / _______ / ______ Age: __________Sex: __________ SSN/Record No.: ___________________________________________ Race/Ethnicity: _____________________________________________ Informant/Relationship: ______________________________________ Medical Home: _____________________________________________ Family Profile and Health Nutrition _____ No change in household since last visit Problems: special diet, inappropriate weight gain, anemic, lead poisoning, chronic GI problems, major food allergies, refusal of any food group* _____ Y _____ N *If answered yes, further assessment needed. Usual Servings Per Day: ____Dairy ____Vegetables __ Fruits ____Breads, cereal, rice, and pasta ____Meat, poultry, fish, eggs, and dry beans Child lives with: _____ Mother _____ Other ____ Father ____ Stepparent _____ Grandparent Total adults living in home: _____________________________ Total children living in home:____________________________ Primary caretaker for this child: __________________________ Relationship: _________________________________________ Family’s concerns/problems: Sensory Mental Health Vision Screen: Hearing Screen: (+ indicates need for futher assessment) ____Special education classes ____No/excessive extracurricular activities ____Substance abuse/use ____Self-concept problems ____Sleep Problems ____Behavior/problems ____Relationship problems with parents, siblings, peers ____Problems in school Grade Level ____________ Comments: Child’s Health/Interim History Allergies: Does the system review note any problems or parent concerns: _____ Y _____ N Explain: Major illness, injury, hospitalization, surgery (since last visit): Medications taken regularly — Type/Reason: _____Normal _____Normal ____ Abnormal ____ Abnormal Health Education Injury Prevention ____Seat belt/auto safety ____Bicycles/ATV ____Athletics ____Water safety ____Smoke detectors ____Firearm safety Behavior ____Substance abuse ____Tobacco use ____Security ____Discipline patterns ____Responsibility ____Communication/conflict resolution Health Promotion ____Limit TV viewing ____Passive smoking ____Regular exercise ____Pubertal changes/sexuality ____Dental care/sealants Nutrition ____Healthy diet/snacks ____Junk food ____Iron-rich foods Assessment Dental Care/sealants: Physical Examination BMI _____________ Temp _________ Pulse ____________Resp ____________ BP ___________ Height ___________Weight___________ (%) ___________ (%) ______________(%) ______________ N A ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ __ __ __ __ __ __ __ __ __ __ NE ___ Appearance ___ Head/fontanels ___ Skin/nodes ___ Eyes ___ Ears ___ Nose ___ Mouth/throat ___ Teeth ___ Neck ___ Chest/breasts (Tanner stage) Additional documentation: N A ____ ____ ____ ____ __ __ __ __ NE ___ Heart/pulses ___ Lungs ___ Abdomen ___ Genitalia/anus (Tanner stage) ____ __ ___ Spine ____ __ ___ Extremities Plan Neurologic: ____ __ ___ Muscle tone ____ __ ___ DTRs TB Risk Screening Tool: _____ Dental referral made: _____ Y _____ N Immunizations: ___Up to date ___ To be given today Explain: Lab: Lead questionnaire (at 6 years): _____ Hct/Hgb ______ Next appointment: ___ Deferred Date: ________________ Signature/Title: __________________________________ Signature/Title ________________________________________ CH-310 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK 2–6 Months If used for documentation:____________________________________ Patient’s Name: ____________________________________________ Date: _____________________________________________________ Key Elements Systems Review Skin: Ears: Rashes, infections Hearing or ear problems Cardio/respiratory: Gastrointestinal: Genitourinary: Neuromuscular: Musculoskeletal: Eyes: Eye discharge, deviation, excessive tearing Nose/Mouth/Throat: Nasal congestion History of murmur, trouble with breathing, wheezing Bowel movementfrequency, problems/concerns, vomiting (Male) Normal stream, number of wet diapers Seizures, coordinated movements Fractures, range of motion Mental Health The mental health assessment of this age also includes the developmentalassessment and informationfrom the family profile. Feelings: Anxious, cries excessively or too little,irritable Behavior: Overactivity,listlessness Social Interaction: Failure to respond socially Thinking: Unattentive Physical Problems: Low weight for age, weight loss, vomits, problem eating, lacks energy, sleeping problems Other: Known history of neglect, physical, sexual or emotional abuse, prenatal substance abuse Progress Notes _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ TDH-ECH-3 Rev. 01/2011 CH-311 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.44 Hearing Checklist for Parents Hearing Checklist for Parents Client Information Name: _________________________________________________________________________ DOB: ________/__________/ ________Age: ______________Sex: _______________________ SSN/Record No.:________________________________________________________________ Race/Ethnicity:__________________________________________________________________ Informant/Relationship: _________________________________________________________ Medical Home: _________________________________________________________________ Age 0 to 3 Yrs Yes No 0 to 3 months ❑ ❑ Does your baby get quiet for a moment when you talk to him/her? ❑ ❑ Does your baby act startled or stop moving for a moment when there are sudden loud noises? ❑ ❑ Does your baby turn his/her eyes or head to the sound of your voice if he/she cannot see you? ❑ ❑ Does your baby smile or stop crying when you or someone else he/she knows speaks? ❑ ❑ Does your baby stop and pay attention when you say “no” or call his/her name? ❑ ❑ Does your baby move his/her head around to try and find out where a new sound is coming from? 4 to 6 months 7 to 9 months ❑ ❑ Does your baby make strings of sounds (“ba ba ba, da da da”)? 10 to 15 months ❑ ❑ Does your baby give you toys or other objects (bottle) when you ask, without your having to use a gesture (holding out your hand or pointing)? ❑ ❑ Does your baby point to familiar objects if you ask (“dog,” “light”)? 16 to 24 months ❑ ❑ Does your child use his/her voice most of the time to get what he/she wants or to communicate with you? ❑ ❑ Can your child go get familiar objects that are kept in a regular place if you ask him/her (“Get your shoes.”)? 25 to 36 months ❑ ❑ Does your child answer different kinds of questions (“When...,” “Who...,” “What...,”)? ❑ ❑ Does your child notice different sounds (telephone ringing, shouting, doorbell)? If you answered “no” to any of the above questions, ask your doctor about a hearing test for your baby. Babies can be tested as soon as the day of birth. Date of visit / / / / / / / / / / / / / / / / / / / / / / / / Age Result Signature of Provider Department of State Health Services Publication No. EFO5-12234 8/05 CH-312 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.45 Hearing Checklist for Parents (Spanish) Lista de comprobación de audición para los padres Información del cliente Nombre: _______________________________________________________________________ Fecha de Nac.: __________/ ________/__________________Edad:________Sexo: _________ No. de SS/Expediente: __________________________________________________________ Raza o etnicidad: _______________________________________________________________ Informante/Parentesco:__________________________________________________________ Médico personal: _______________________________________________________________ De 0 a 3 años Sí No De 0 a 3 meses ❑ ❑ ¿Su bebé se tranquiliza por un momento cuando le habla? ❑ ❑ ¿Su bebé actúa sorprendido o deja de moverse por un momento cuando hay ruidos fuertes repentinos? ❑ ❑ ¿Su bebé dirige la mirada o gira la cabeza hacia el sonido de su voz si no la está viendo? ❑ ❑ ¿Su bebé sonríe o deja de llorar cuando le habla usted u otra persona que él conoce? ❑ ❑ ¿Su bebé deja de hacer lo que está haciendo y pone atención cuando le dice "no" o lo llama por su nombre? ❑ ❑ ¿Su bebé gira la cabeza hacia todos lados y trata de encontrar de dónde viene algún sonido nuevo? De 4 a 6 meses De 7 a 9 meses ❑ ❑ ¿Su bebé hace sonidos repetidos ("gu-gú, da-dá")? De 10 a 15 meses ❑ ❑ ¿Su bebé le da a usted juguetes u otros objetos (la botella) cuando se los pide, sin tener que usar gestos (extender la mano o señalar)? ❑ ❑ ¿Su bebé señala con el dedo objetos familiares si se lo pide ("el perro", "la luz")? De 16 a 24 meses ❑ ❑ ¿Su hijo usa principalmente la voz para conseguir lo que quiere o cuando quiere comunicarse con usted? ❑ ❑ ¿Su hijo puede ir a buscar objetos familiares guardados en lugares regulares si usted se lo pide ("Vé por tus zapatos")? De 25 a 36 meses ❑ ❑ ¿Su hijo responde a diferentes tipos de preguntas ("Cuándo", "Quién", "Qué")? ❑ ❑ ¿Su hijo distingue sonidos diferentes (el timbre del teléfono, gritos, el timbre de la puerta)? Si contestó "No" a cualquiera de las preguntas anteriores pida a su médico un examen auditivo para su bebé. Se puede examinar a los bebés tan pronto como el día de su nacimiento. Fecha de la visita Edad / / / / / / / / / / / / / / / / / / / / / / / / Resultado Firma del proveedor Departamento de servicios médicos estatales Publicacién No. EFO5-12234 8/05 CH-313 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.46 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) Mental Health Interview Tool/Referral Form (Ages 0–2 Years) Mental Health Interview Tool/Referral Form Child’s Name: ____________________________ Birth Date: _______________________________ Ages 0 to 2 Date: ____________________________________ For this age group you will obtain information from the parent/caregiver and from your own observations of the child. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Does your child display feelings that concern you or seem out of the ordinary? Behavior: Does your child display behavior that concerns you or seems out of the ordinary for his/ her age? Social Interaction: Do you have concerns about how your child gets along with you? Other family members or adults? Siblings? Thinking: Do you think your child’s development is normal for age? Physical Problems: Do you have any concerns about your child’s physical health? If physical problems exist, have they been medically evaluated? Infants 1 to 2 Years ❏ Anxious ❏ Irritable ❏ Sullen ❏ Cries excessively ❏ Angry ❏ Anxious ❏ Cries too little ❏ Sad ❏ Cries excessively ❏ Fearful ❏ Cries too little Infants 1 to 2 Years ❏ Overactive ❏ Overactive ❏ Listlessness ❏ Listlessness ❏ Harms others ❏ Frequent temper tantrums Infants 1 to 2 Years ❏ No eye contact or smile ❏ * No eye contact or smile ❏ Stiffens and arches ❏ Clings excessively ❏ Not responsive ❏ Not responsive ❏ Language delay Infants (> 8 months) 1 to 2 Year ❏ ❏ Mistrustful ❏ Problems concentrating or paying attention No communication skills (pointing to request an object) or efforts to make words Infants to 2 Years ❏ Low weight or weight loss ❏ Frequent vomiting ❏ Eating problem (poor appetite, eats nonfoods) ❏ Sleeping problem (frequent night waking) ❏ Lethargic Other: Are there any situations which are causing your family particular stress at this time? Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what form, when, treatment initiated, etc.? Did the mother of this child use drugs or drink alcohol during the pregnancy? Comments: Signature/Title: _______________________________________________________________________________________ CH-314 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.47 Mental Health Interview Tool/Referral Form (Ages 3–9 Years) Mental Health Interview Tool/Referral Form (Ages 3–9 Years) Mental Health Interview Tool/Referral Form Child’s Name: ____________________________ Birth Date: _______________________________ Date: _____________________________________ Ages 3 to 9 For this age group you will obtain information from the parent/caregiver and from your own observations of the child’s behavior. If possible, interview the parent alone when asking questions about sexual or physical abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Behavior: Does your child display feelings that concern you or seem out of Does your child frequently display behavior that seems out of the the ordinary for age? ordinary for age? ❏ ❏ ❏ ❏ ❏ ❏ ❏ Restless Sad or cries easily Excessively guilty Lack of remorse Irritable, angers or temper tantrums easily Sullen Fearful or anxious ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ Problems in school * Harms other children or animals Lacks interest in things s/he used to enjoy Engages in sexual play with others, toys, animals * Destroys possessions or other property Steals Refuses to talk * Sets fires Overactive * Self-destructive * Has been in trouble with the police (older child) Social Interaction: Thinking: Do you have concerns about how child gets along with you, other Have you noticed any of the following to be a problem for your child? family members, playmates, other adults? ❏ Withdraws including no eye contact ❏ * Frequently confused ❏ Clings excessively ❏ Daydreams excessively ❏ Difficulty making and keeping friends ❏ Distracted, doesn’t pay attention ❏ Defiant, a discipline problem ❏ * Bizarre thoughts ❏ Severe or frequent tantrums ❏ Mistrustful ❏ Aggressive ❏ ❏ ❏ Argues excessively Refuses to go to school ❏ ❏ * Sees or hears things that are not there (excluding imaginary friends in younger children) Blames others for his/her misdeeds or thoughts * Talks about death ❏ Prefers to be alone ❏ ❏ * Frequent memory loss Schoolwork is slipping (grades going down) Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Daytime wetting ❏ Soils pants ❏ Refusal to eat ❏ Headaches ❏ Excessive weight loss or gain ❏ Sleep problems, nightmares, sleep-walking, early waking ❏ Vomits frequently ❏ Frequent stomachaches ❏ Lacks energy Other: Is this child accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. * Is this child at risk for out-of-home placement because of behavior problems? Comments: Signature/Title: _____________________________________________________________________________ CH-315 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.48 Mental Health Interview Tool/Referral Form (Ages 10–12 Years) Mental Health Interview Tool/Referral Form (Ages 10–12 Years) Mental Health Interview Tool/Referral Form Child’s Name: ____________________________ Birth Date: _______________________________ Ages 10 to 12 Date: _____________________________________ Both child and parent will be able to provide information, and it is important to incorporate the child into the interview process. In each section, a sample question is directed toward the parent. To the extent possible, elicit the child’s perception of the parent’s response with a question such as “Do you agree with what your Mom is saying?” It may be useful to allow time for discussion with the caregiver alone. The child should be interviewed alone when asking questions about sexual or physical abuse and about substance abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.. Feelings: Behavior: Does your child (do you) have feelings that concern you or seem Does your child (do you) behave in ways that seems out of the out of the ordinary for age? ordinary for age? ❏ Restless ❏ Problems in school ❏ Sad or cries easily ❏ * Threatens or harms other children or animals ❏ Guilty ❏ Lacks interest in things s/he used to enjoy ❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals ❏ Sullen ❏ * Destroys possessions or other property ❏ Fearful or anxious ❏ Steals ❏ Bored ❏ Refuses to talk ❏ * Sets fires ❏ Overactive ❏ * Has been in trouble with the police ❏ * Self-destructive Social Interaction: Thinking: Do you have concerns about how your child (you) gets along with Have you noticed any of the following to be a problem for your child family members, other adults or children? (you)? ❏ Prefers to be alone ❏ * Frequently confused ❏ Difficulty making and keeping friends ❏ Daydreams excessively ❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention ❏ Aggressive ❏ Mistrustful ❏ Argues excessively ❏ * Sees or hears things that are not there ❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts ❏ * Talks about death or suicide ❏ * Frequent memory loss ❏ * Bizarre thoughts ❏ Schoolwork is slipping (grades going down) Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Lacks energy ❏ Uses laxatives ❏ Vomits frequently ❏ Food refusal, secretive eating ❏ Frequent stomachaches ❏ Headaches ❏ Excessive weight loss or gain ❏ Sleep problems, nightmares, sleep-walking, early waking, frequent night waking Other: Is this child (are you) accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. ❏ * Is this child at risk for out-of-home placement because of behavior problems? ❏ Has the child (have you) been treated for mental health problems or substance abuse? Substance Abuse Questions: (May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.) ❏ Has been identified as a problem Comments: Signature/Title: _____________________________________________________________________________ CH-316 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.49 Mental Health Interview Tool/Referral Form (Ages 13–20 Years) Mental Health Interview Tool/Referral Form (Ages 13–20 Years) Mental Health Interview Tool/Referral Form Child’s Name: ____________________________ Birth Date: _______________________________ Ages 13 to 20 Date: _____________________________________ You may begin with a joint interview or begin with separate interviews with the parent/caregiver and adolescent. It is preferable to interview the adolescent first. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation. Feelings: Behavior: Do you (does your teen) have feelings that concern you or seem Do you (does your child) behave in ways that seems out of the out of the ordinary for (their) age? ordinary for your (their) age? ❏ Restless ❏ Problems at school or work ❏ Sad or cries easily ❏ * Threatens or harms other children or animals ❏ Guilty ❏ Lacks interest in things s/he used to enjoy ❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals ❏ Sullen ❏ * Destroys possessions or other property ❏ Fearful or anxious ❏ Steals ❏ Bored ❏ Refuses to talk ❏ * Sets fires ❏ Overactive ❏ * Has been in trouble with the police ❏ * Self-destructive Social Interaction: Thinking: Do you have concerns about how (you) your child gets along with Have you noticed any of the following to be a problem for you (your family members, other adults, or peers? child)? ❏ Prefers to be alone ❏ * Frequently confused ❏ Difficulty making and keeping friends ❏ Daydreams excessively ❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention ❏ Aggressive ❏ Mistrustful ❏ Argues excessively ❏ * Sees or hears things that are not there ❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts ❏ * Talks about death or suicide ❏ * Frequent memory loss ❏ * Bizarre thoughts ❏ Schoolwork is slipping (grades going down) Physical Problems: Do you have any concerns about the following physical signs? Has this been evaluated? ❏ Lacks energy ❏ Uses laxatives ❏ ❏ ❏ ❏ ❏ ❏ Vomits frequently Food refusal, secretive eating Frequent stomachaches Headaches Excessive weight loss or gain Sleep problems, nightmares, sleep-walking, early waking, frequent night waking Other: Are you (is this child) accident-prone? Are there any situations that are causing your family particular stress? Have you (has this child) or your (his/her) parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc. ❏ * Are you (is this child) at risk for out-of-home placement because of behavior problems? ❏ Have you (has this child) been treated for mental health problems or substance abuse? Substance Abuse Questions: (May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.) ❏ Has been identified as a problem Comments: Signature/Title: ____________________________________________________________________________ CH-317 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.50 Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages) Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages) Mental Health Parent Questionnaire Child’s Name: ____________________________ Birth Date: _______________________________ Today’s Date: ____________________________ Ages Birth to 2 Years To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No B e h a v i o r Does your child do things that concern you or seem strange for their age? ❑ Yes ❑ No S o c i a l I n t e r a c t i o n Infants 1 to 2 Years ❑ Fearful ❑ Is irritable ❑ Fearful ❑ Cries too much ❑ Is angry ❑ Cries too little ❑ Cries too little ❑ Is sad ❑ Cries too much ❑ Is sullen Infants 1 to 2 Years ❑ Is overactive ❑ Is overactive ❑ Harms others ❑ Is listless (has little energy) ❑ Is listless (has little energy) ❑ Has temper tantrums often Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No With other family members or adults? ❑ Yes ❑ No With brothers and sisters? ❑ Yes ❑ No Infants 1 to 2 Years ❑ Does not make eye contact or smile ❑ Does not make eye contact ❑ Does not respond to you ❑ Stiffens and arches back or smile ❑ Clings to you too much ❑ Does not say any words yet ❑ Does not respond to you T Do you think your child is as bright and thinks as clearly as others their age? ❑ Yes ❑ No h Infants 1 to 2 Years i n ❑ Does not trust others k ❑ (>8 months) Does not point to or ask for things or try to make words ❑ Has problems concentrating or paying attention i n g CH-318 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK P h y s i c a l P r o b l e m s Do you have any concerns about these things? ❑ Yes ❑ No If you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No Infants to 2 Years ❑ Is low weight or has a lot of weight ❑ Has sleeping problems (wakes a lot at night) ❑ Vomits (throws up) often ❑ Has little energy ❑ Has eating problems (poor appetite, eats non-foods) O t h e r Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Did the mother of this child use drugs or alcohol during the pregnancy? ❑ Yes ❑ No Comments: (Please write anything else you want us to know about in this space.) Date: ____________ Signature: ______________________________________________________ Relation to patient: _______________________________________________ CH-319 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.51 Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres Nombre del Niño:________________________________ Fecha de Nacimiento: ___________________________ Fecha: _________________________________________ De Recién Nacido a 2 Años de Edad Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su bebé. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su bebé. Favor de marcar todas las características abajo que son ciertas para su bebé. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. S E N T I M I E N T O S ¿Tiene su bebé sentimientos que le preocupan o tal vez parezcan extraños para su edad? C O M P O R T A M I E N T O ¿Hace su bebé cosas que le preocupan o que parezcan extrañas para su edad? I N T E R A C C I O N E S Bebés P E N S A M I E N T O S ❏ No De 1 a 2 Años ❏ Siente miedo ❏ Llora mucho ❏ Llora muy poco ❏ ❏ ❏ ❏ Es de mal carácter Es enojón Es triste ❏ Siente miedo ❏ Llora muy poco ❏ Llora mucho Es malhumorado ❏ Sí ❏ No ¿Se preocupa sobre cómo se lleva su bebé con usted? ¿Con otros miembros de la familia o adultos? ❏ Sí ❏ Sí ❏ No ❏ No ¿Con sus hermanos o hermanas? ❏ Sí ❏ No Bebés De 1 a 2 Años ❏ Es demasiado activo ❏ Es indiferente (tiene poca energía) S O C I A L E S ❏ Sí Bebés ❏ ❏ ❏ ❏ Es demasiado activo Es indiferente (tiene poca energía) Lastima a otros Hace berrinches frecuentemente De 1 a 2 Años ❏ No ve a los ojos ni sonríe ❏ Se pone tieso y se dobla arqueando la espalda ❏ No le responde ❏ ❏ ❏ ❏ No ve a los ojos ni sonríe La mayoría del tiempo no se le despega No le responde Todavía no dice ninguna palabra ¿Piensa usted que su nino es tan inteligente y que piensa tan claramente como otros niños de su edad? Bebés ❏ Sí ❏ No De 1 a 2 Años ❏ (>8 meses) No pide ni senala a las cosas o trata de decir palabras ❏ No le tiene confianza a otros ❏ Tiene problemas para concentrarse y poner atención CH-320 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK ¿Se preocupa usted sobre los siguientes problemas físicos? Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con un médico o una enfermera debido a ese problema? P R O B L E M A S F I S I C O S ❏ No ❏ Sí ❏ No De recién nacidos a 2 Años ❏ Es de peso bajo o ha perdido mucho peso ❏ Se vomita frecuentemente ❏ Tiene problemas para comer (muy poco apetito, come alimentos que no son saludables) O T R O S ❏ Sí ❏ Tiene problemas para dormir (se despierta mucho durante la noche) ❏ Tiene muy poca energía ¿Hay algo que le esté causando tensión a su familia ahora? ❏ Sí ❏ No ¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físicos, sexual o emocional? Si sí, ¿en qué forma?_____________________ ¿Cuándo?_____________ ¿Empezó el tratamiento? ❏ Sí ❏ No ❏ Sí ❏ No ¿Usó drogas o tomó bebidas alcohólicas durante su embarazo la mamá de este niño? ❏ Sí ❏ No Comentarios: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.) Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________ CH-321 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.52 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) Mental Health Parent Questionnaire Child’s Name: ____________________________ Birth Date: _______________________________ Ages 3 to 9 Years Today’s Date: ____________________________ To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No B e h a v i o r Does your child do things that seem strange for their age? ❑ Yes ❑ No S o c i a l I n t e r a c t i o n T h i n k i n g ❑ Is restless ❑ Is irritable, angers or temper tantrums easily ❑ Is sad or cries easily ❑ Is sullen ❑ Is overly guilty ❑ Fearful ❑ Lacks remorse ❑ Has problems in school ❑ Refuses to talk ❑ Harms other children or animals ❑ Sets fires ❑ Lacks interest in things s/he used to enjoy ❑ Is over-active ❑ Plays sexual games with others, toys, animals ❑ Hurts himself or herself ❑ Destroys possessions or other property ❑ Has been in trouble with the police ❑ Steals Do you have any concerns about how your child gets along with you? ❑ Yes ❑ No With other family members or adults? ❑ Yes ❑ No ❑ No With playmates? ❑ Yes ❑ Withdraws and does not look into peoples’ eyes ❑ Picks on others a lot or often gets into fights (hitting, etc.) ❑ Clings to you too much ❑ Argues too much ❑ Has a hard time making and keeping friends ❑ Will not go to school ❑ Is defiant, has a disciplinary problem ❑ Prefers to be alone ❑ Severe or frequent tantrums Are any of these a problem for your child? ❑ Yes ❑ No ❑ Is frequently confused (does not understand what is going on) ❑ Daydreams a lot ❑ Is distracted, doesn’t pay attention ❑ Has very strange thoughts ❑ Schoolwork is slipping (grades going down) ❑ Does not trust others ❑ Sees or hears things that are not there ❑ Blames others for his/her misdeeds or thoughts ❑ Talks about death a lot ❑ Often cannot remember things CH-322 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK Do you have any concerns about these things? ❑ Yes ❑ No If you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No P h y s i c a l P r o b l e m s O t h e r Is this child accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Is this child at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No ❑ Has daytime wetting ❑ Has sleeping problems, nightmares, sleep-walking, early waking ❑ Soils pants ❑ Vomits (throws up) often ❑ Will not eat ❑ Has stomach aches often ❑ Has headaches ❑ Lacks energy ❑ Has lost or gained a lot of weight Comments: (Please write anything else you want us to know about in this space.) Date: ____________ Signature: ______________________________________________________ Relation to patient: _______________________________________________ CH-323 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.53 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish) Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 3 a 9 Años de Edad Nombre del Niño:________________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________ Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su niño. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que sean ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. S E N T I M I E N T O S ¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? C O M P O R T A M I E N T O ¿Hace su niño cosas que le parezcan extrañas para su edad? I N T E R A C C I O N E S ❏ ❏ ❏ ❏ ❏ Sí ❏ No ❏ Es de mal carácter, enojón o hace berrinches Es inquieto Es triste o llora fácilmente Se siente muy culpable No tiene remordimiento temperamentales fácilmente ❏ Es malhumorado ❏ Siente miedo ❏ Sí ❏ No ¿Se preocupa sobre cómo se lleva su niño con usted? ¿Con otros miembros de la familia o adultos? ❏ Sí ❏ Sí ❏ No ❏ No ¿Con sus compañeros de juego? ❏ Sí ❏ No ❏ ❏ ❏ ❏ Tiene problemas en la escuela Lastima a otros niños o a los animales No le interesan las cosas que antes le gustaban Juega juegos sexuales con otros niños, juguetes, o animales ❏ ❏ ❏ ❏ ❏ Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía ❏ Destruye cosas personales u ajenas ❏ Roba S O C I A L E S ❏ ❏ ❏ ❏ ❏ Se aleja y no ve a nadie a los ojos La mayoría del tiempo no se le despega Se le dificulta hacer y mantener amistades Es desafiante, tiene un problema de disciplina Hace berrinches tempermentales fuertes o ❏ Siempre molesta a otros o frecuentemente se pelea (pegando, etc.) ❏ Discute mucho ❏ No quiere asistir a la escuela ❏ Prefiere estar solo frecuentemente ❏ Sí ¿Son algunas de estas características un problema para su niño? P E N S A M I E N T O S ❏ Se confunde frecuentemente (no entiende lo que está pasando) ❏ ❏ ❏ ❏ Sueña mucho despierto Se distrae, no pone atención Tiene pensamientos muy extraños Se está atrasando en el trabajo de la escuela (sus grados están bajando) ❏ No ❏ No le tiene confianza a los demás ❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus pensamientos ❏ Habla mucho sobre la muerte ❏ Frecuentemente no se acuerda de cosas CH-324 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK P R O B L E M A S F I S I C O S O T R O S ¿Se preocupa usted sobre los siguientes problemas físicos? Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con un médico o una enfermera debido a ese problema? ❏ ❏ ❏ ❏ ❏ Se orina durante el día Ensucia sus pantalones No quiere comer Tiene dolores de cabeza Ha perdido o aumentado mucho de peso ❏ ❏ Sí ❏ No ❏ Sí ❏ No Tiene problemas para dormir, pesadillas, se despierta temprano y sonámbulo ❏ Se vomita frecuentemente ❏ Tiene dolores de estómago frecuentemente ❏ No tiene energía ¿Es propenso este niño a tener accidentes? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? ❏ Sí ❏ Sí ❏ No ❏ No Si sí, ¿en qué forma?_________________ ❏ Sí ❏ No ¿Cuándo? ___________ ¿Empezó el tratamiento? ❏ Sí ❏ No ¿Corre el riesgo este niño de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ❏ Sí ❏ No Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.) Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________ CH-325 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.54 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) Mental Health Parent Questionnaire Child’s Name: _____________________________ Birth Date: ________________________________ Ages 10 to 12 Years Today’s Date: _____________________________ To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s Does your child (do you) show feelings that concern you or seem strange for their (your) age? ❑ Yes ❑ No B e h a v i o r Does your child (do you) often do things that seem strange for their (your) age? ❑ Yes ❑ No S o c i a l I n t e r a c t i o n T h i n k i n g Are any of these a problem for your child (you)? ❑ Yes ❑ No ❑ Is restless ❑ Is sullen ❑ Is sad or cries easily ❑ Is fearful ❑ Is guilty ❑ Is bored ❑ Is irritable or angers easily ❑ Has problems in school ❑ Refuses to talk ❑ Threatens or harms other children or animals ❑ Sets fires ❑ Lacks interest in things s/he used to enjoy ❑ Is overactive ❑ Is involved in sexual activity ❑ Hurts himself or herself ❑ Destroys possessions or other property ❑ Has been in trouble with the police ❑ Steals Do you have any concerns about how your child (you) get(s) along with family members? ❑ Yes ❑ No ❑ No With other adults? ❑ Yes With other children? ❑ Yes ❑ No ❑ Prefers to be alone ❑ Picks on others a lot or often gets into fights (hitting, etc.) ❑ Has a hard time making and keeping friends ❑ Argues too much ❑ Is defiant, a disciplinary problem ❑ Will not go to school ❑ Is frequently confused (does not understand what is ❑ Does not trust others going on) ❑ Daydreams a lot ❑ Is distracted, doesn’t pay attention ❑ Has very strange thoughts ❑ Schoolwork is slipping (grades going down) ❑ Sees or hears things that are not there ❑ Blames others for his/her misdeeds or thoughts ❑ Talks about death or suicide a lot ❑ Often cannot remember things CH-326 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK Do you have any concerns about these things? ❑ Yes ❑ No If you think your child (you) may have a health problem, has he/she (have you) seen a doctor or nurse about the ❑ No problem? ❑ Yes P h y s i c a l P r o b l e m s O t h e r Is your child (you) accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Is this child (are you) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No Does your child (do you) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No Has this child (have you) been treated for mental health problems or substance abuse? ❑ Yes ❑ No ❑ Lacks energy ❑ Has headaches ❑ Uses laxatives ❑ Has lost or gained a lot of weight ❑ Vomits (throws up) often ❑ Has sleeping problems, nightmares, sleep-walking, early waking, ❑ Won’t eat in front of people, sneaks food frequent night waking later ❑ Has stomach aches often Comments: (Please write anything else you want us to know about in this space.) Date: ____________ Signature: ______________________________________________________ Relation to patient: _______________________________________________ CH-327 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.55 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish) Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 10 a 12 Años de Edad Nombre del Niño:_________________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________ Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problématica que tenga su hijo. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que son ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. ¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? S E N T I M I E N T O S ❏ ❏ ❏ ❏ C O M P O R T A M I E N T O I N T E R A C C I O N E S Es triste o llora fácilmente Se siente culpable ❏ Sí ❏ No Es de mal carácter o se enoja fácilmente ❏ Tiene problemas en la escuela ❏ Amenaza o lastima a otros niños o a los animales ❏ ❏ ❏ ❏ ❏ No ❏ Es malhumorado ❏ Siente miedo ❏ Se aburre ¿Hace su niño cosas que le parezcan extrañas para su edad? S O C I A L E S P E N S A M I E N T O S Es inquieto ❏ Sí No le interesan las cosas que antes le gustaban Participa en actividades sexuales ❏ ❏ ❏ ❏ ❏ Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía Destruye cosas personales o ajenas Roba ¿Se preocupa sobre cómo se lleva su niño con usted? ¿Con otros adultos? ¿Con otros niños? ❏ Prefiere estar solo ❏ Se le dificulta hacer y mantener amistades ❏ Es desafiante, tiene un problema de disciplina ¿Son algunas de estas características un problema para su niño? ❏ Se confunde frecuentemente (no entiende lo que está pasando) ❏ Sueña mucho despierto ❏ Sí ❏ Sí ❏ Sí ❏ ❏ No ❏ No ❏ No Siempre molesta a otros o frecuentemente se pelea (pegando, etc.) Discute mucho ❏ ❏ No quiere asistir a la escuela ❏ Sí ❏ No ❏ No le tiene confianza a los demás ❏ Se distrae, no pone atención ❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus ❏ Tiene pensamientos muy extraños ❏ Se está atrasando en el trabajo de la escuela (sus ❏ Habla mucho sobre la muerte o del suicidio ❏ Frecuentemente no se acuerda de cosas grados están bajando) pensamientos CH-328 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK P R O B L E M A S F I S I C O S ¿Se preocupa usted sobre los siguientes problemas físicos? Si piensa que su niño tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera debido a ese problema? ❏ La falta energía ❏ Usa laxantes ❏ Se vomita frecuentemente ❏ Sí ❏ Sí ❏ No ❏ No ❏ Tiene dolores de cabeza ❏ Ha perdido o aumentado mucho peso ❏ Tiene problemas para dormir, pesadillas, sonambulismo, despierta temprano, despierta seguido por la noche ❏ No come delante de la gente, come después a escondidas ❏ Tiene dolores de estómago frecuentemente O T R O S ¿Es propenso a tener accidentes su niño? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha sido este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ¿Empezó el tratamiento? ¿Corre este niño el riesgo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ¿Toma bebidas alcohólicas o usa drogas su niño (incluyendo las de la calle y las que se venden sin receta)? ¿Ha recibido su niño tratamiento por problemas de la salud mental o por el abuso de sustancia como las drogas y bebidas alcohólicas? ❏ Sí ❏ Sí ❏ No ❏ No ❏ Sí ❏ Sí ❏ Sí ❏ Sí ❏ Sí ❏ ❏ ❏ ❏ ❏ No No No No No Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.) Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________ CH-329 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.56 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) Mental Health Parent Questionnaire Teen’s Name: ____________________________ Birth Date: _______________________________ Ages 13 to 20 Years Today’s Date: ____________________________ To the Teen or Parent: If you will assist us by filling out this form, we can help you find your (your teen’s) strengths and any problem areas, too. Your answers will help us to know if we need to talk with you (your teen) and find out more about you (your teen). Please check all items below that are true for you (your teen). Some of the behaviors noted may be normal but if you are concerned please let us know. F e e l i n g s Do you (does your teen) show feelings that concern you or seem strange for your (their) age? ❑ Yes ❑ No B e h a v i o r Do you (does your teen) often do things that seem strange for your (their) age? ❑ Yes ❑ No S o c i a l I n t e r a c t i o n T h i n k i n g Are any of these a problem for you (your teen)? ❑ Yes ❑ No ❑Restless ❑ Sullen ❑Sad or cry easily ❑ Fearful ❑Guilty ❑ Bored ❑ Irritable or angered easily ❑ Have problems in school or work ❑ Refuse to talk ❑ Threaten or harm other children or animals ❑ Set fires ❑ Lack interest in things you used to enjoy ❑ Over-active ❑ Is involved in sexual activity ❑ Hurt yourself ❑ Destroy possessions or other property ❑ Have been in trouble with the police ❑ Steal Do you have any concerns about how you (your teen) get(s) along with family members? ❑ Yes ❑ No With other adults? ❑ Yes ❑ No With peers? ❑ Yes ❑ No ❑ Prefer to be alone ❑ Pick on others a lot or often get into fights (hitting, etc.) ❑ Have a hard time making and keeping friends ❑ Argue too much ❑ Defiant, a disciplinary problem ❑ Will not go to school ❑ Frequently confused (does not understand what is going ❑ Do not trust others on) ❑ Daydream a lot ❑ Distracted, do not pay attention ❑ Have very strange thoughts ❑ Schoolwork is slipping (grades going down) ❑ See or hear things that are not there ❑ Blame others for your misdeeds or thoughts ❑ Talk about death or suicide a lot ❑ Often cannot remember things CH-330 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK Do you have any concerns about these things? ❑ Yes ❑ No If you think you (your teen) may have a health problem, have you (has he/she) seen a doctor or nurse about the problem? ❑ Yes ❑ No P h y s i c a l P r o b l e m s O t h e r Are you (is your teen) accident-prone? ❑ Yes ❑ No Is anything causing your family stress right now? ❑ Yes ❑ No Have you (has your teen) or your parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ No Treatment initiated? ❑ Yes ❑ No Are you (is this teen) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No Do you (does your child) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ No Have you (has this teen) been treated for mental health problems or substance abuse? ❑ Yes ❑ No ❑ Lack energy ❑ Have headaches ❑ Use laxatives ❑ Have lost or gained a lot of weight ❑ Vomit (throw up) often ❑ Have sleeping problems, nightmares, sleep-walking, early waking, ❑ Won’t eat in front of people, sneak food frequent night waking later ❑ Have stomachaches often Comments: (Please write anything else you want us to know about in this space.) Date: ____________ Signature: ______________________________________________________ Relation to patient: _______________________________________________ CH-331 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.57 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish) Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish) Cuestionario de la Salud Mental para los Padres De 13 a 20 Años de Edad Nombre del Adolescente:__________________________ Fecha de Nacimiento: ____________________________ Fecha: _________________________________________ Para los Padres: Si nos ayuda llenando este formulario, podremos ayudarle a encontrar las áreas fuertes que tenga su hijo y también cualquier área problématica. Sus respuestas nos ayudarán a saber si necesitamos hablar con su hijo y saber más sobre él. Favor de marcar todas las características abajo que son ciertas para su hijo. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos. S E N T I M I E N T O S ¿Tiene su hijo sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Es inquieto C O M P O R T A M I E N T O ¿Hace su hijo cosas frecuentemente que le parezcan extrañas para su edad? ❏ Tiene problemas en la escuela o en el trabajo I N T E R A C C I O N E S ❏ Es triste o llora fácilmente ❏ Se siente culpable ❏ Es irrita o enoja fácilmente ❏ ❏ ❏ ❏ ❏ S O C I A L E S P E N S A M I E N T O S Amenaza o lastima a otros niños o a los animales No le interesan las cosas que antes le gustaban Está envuelto en actividades sexuales Destruye cosas personales u otras cosas ajenas ❏ Sí ❏ No ❏ Es malhumorado ❏ Siente miedo ❏ Se aburre ❏ Sí ❏ ❏ ❏ ❏ ❏ ❏ No Se niega a hablar Provoca incendios Es demasiado activo Se lastima Ha tenido problemas con la policía Roba ¿Le preocupa cómo se lleva su hijo con los miembros de la familia? ¿Con otros adultos? ¿Con su grupo social? ❏ Prefiere estar solo ❏ Se le dificulta hacer y mantener amistades ❏ Es desafiante, tiene un problema de disciplina ¿Son algunas de estas características un problema para su hijo? ❏ Se confunde frecuentemente (no entiende lo que está pasando) ❏ Sueña mucho despierto ❏ Sí ❏ No ❏ Sí ❏ Sí ❏ No ❏ No Molesta mucho a otros o frecuentemente se pelea (pegando, etc.) Discute mucho ❏ ❏ ❏ No quiere asistir a la escuela ❏ Sí ❏ No ❏ No le tiene confianza a los demás ❏ Se distrae, no pone atención ❏ Mira u oye cosas que no están allí ❏ Culpa a otros por algo que hizo mal o por sus ❏ Tiene pensamientos muy extraños ❏ Se está atrasando en el trabajo de la escuela (sus ❏ Habla mucho sobre la muerte o el suicidio ❏ Frecuentemente no se acuerda de cosas grados están bajando) pensamientos CH-332 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK P R O B L E M A S F I S I C O S ¿Se preocupa por estas cosas? Si piensa que su hijo tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera por este problema? ❏ No tiene energía ❏ Usa laxantes ❏ Se vomita frecuentemente ❏ Sí ❏ Sí ❏ No ❏ No ❏ Tiene dolores de cabeza ❏ Ha perdido o aumentado mucho peso ❏ Tiene problemas para dormir, pesadillas, se despierta temprano, sonámbulo y frecuentemente despierta durante la noche ❏ No come delante de la gente, come después a esconidas ❏ Tiene dolores de estómago frecuentemente O T R O S ¿Es su hijo propenso a tener accidentes? ¿Hay algo que le está causando tensión a su familia ahora? ¿Ha sido su hijo o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ¿Empezó el tratamiento? ¿Corre el riesgo su hijo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ¿Toma su hijo bebidas alcohólicas o drogas (incluyendo las de la calle y las que se venden sin receta)? ¿Ha recibido su hijo tratamiento por problemas de la salud mental o por el abuso de sustancias como drogas o bebidas alcohólicas? ❏ Sí ❏ Sí ❏ Sí ❏ No ❏ No ❏ No ❏ Sí ❏ Sí ❏ Sí ❏ Sí ❏ ❏ ❏ ❏ No No No No Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.) Fecha:_____________ Firma:________________________________________________________________ Parentesco con el paciente:_____________________________________________ table CH-333 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 Risk Assessment for Lead Exposure: Parent Questionnaire, Form Pb-110 (2 Pages) Risk Assessment for Lead Exposure: Parent Questionnaire Form CH.58 Pb - 110 The risk assessment questionnaire contains 6 questions that appear on page 2, and is designed to be administered to the parent by the healthcare provider. Questions are in English and Spanish to assist with Spanish speaking parents. Instructions: 7KLVTXHVWLRQQDLUHPD\EHXVHGZLWKDQ\FKLOGZKHWKHURUQRWHQUROOHGLQ7H[DV+HDOWK6WHSV 0HGLFDLGUHTXLUHVDEORRGOHDGWHVWIRUDOO7H[DV+HDOWK6WHSVSDWLHQWVDWPRQWKVDQGPRQWKV )RUFKLOGUHQOHVVWKDQ\HDUVRI DJHFRPSOHWHDEORRGOHDGWHVWDWDQ\ILUVWFKHFNXSDIWHUDJHDQG PRQWKVLI WKHUHLVQRHYLGHQFHRI DSUHYLRXVEORRGOHDGWHVW $WDQ\YLVLW\RXPD\FKRRVHWRSHUIRUPDEORRGOHDGWHVWUDWKHUWKDQXVHWKHULVNDVVHVVPHQW TXHVWLRQQDLUH 5HIHUWRWKHWDEOHEHORZIRUVFKHGXOLQJXVHRI WKHULVNDVVHVVPHQWTXHVWLRQQDLUH $´\HVµRU´GRQ·WNQRZµDQVZHUWRDQ\TXHVWLRQRQWKHULVNDVVHVVPHQWTXHVWLRQQDLUHLQGLFDWHVWKDWD EORRGOHDGWHVWVKRXOGEHDGPLQLVWHUHG Schedule for Blood Lead Testing and Use of Risk Assessment Questionnaire Child’s Age Parent Questionnaire 6 months YES 9 months YES 12 months Blood Lead Test YES 15 months YES 18 months YES 24 months YES 30 months YES 3, 4, 5, and 6 years YES For more information, contact the Texas Childhood Lead Poisoning Prevention Program at: 1-800-588-1248 http://www.dshs.state.tx.us/lead Fax completed form to 512-458-7699, or mail to the address below. 7H[DV&KLOGKRRG/HDG3RLVRQLQJ3UHYHQWLRQ3URJUDP 32%2;$XVWLQ7;ZZZGVKVVWDWHW[XVOHDG3DJHRI 5HYLVHG CH-334 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Form CHILDREN’S SERVICES HANDBOOK Pb - 110 Risk Assessment for Lead Exposure: Parent Questionnaire Healthcare Provider: For children less than 6 years of age, complete a blood lead test at any first checkup after age 12 and 24 months if there is no evidence of a previous blood lead test. 3DWLHQW·V1DPH 3URYLGHU·V1DPH '2% $GPLQLVWHUHGE\ 0HGLFDLG 'DWH Parent Questionnaire 1 'RHV\RXUFKLOGOLYHLQRUYLVLWDKRPHGD\FDUHRURWKHUEXLOGLQJEXLOWEHIRUH" 2 'RHV\RXUFKLOGOLYHLQRUYLVLWDKRPHGD\FDUHRURWKHUEXLOGLQJZLWKRQJRLQJUHSDLUVRUUHPRGHOLQJ" 3 'RHV\RXUFKLOGHDWRUFKHZRQQRQIRRGWKLQJVOLNHSDLQWFKLSVRUGLUW" 4 'RHV\RXUFKLOGKDYHDIDPLO\PHPEHURUIULHQGZKRKDVRUGLGKDYHDQHOHYDWHGEORRGOHDGOHYHO" 5 ,V\RXUFKLOGDQHZO\DUULYHGUHIXJHHRUIRUHLJQDGRSWHH" 6 ,V\RXUFKLOGH[SRVHGWRDQ\RI WKHIROORZLQJLI <(6FKHFNDOOWKDWDSSO\ Yes Don’t know If “Yes” or “Don’t Know” Perform a Blood Lead Test Contamination from a parent, relative, or friend with jobs or hobbies like these? R R R R R 5DGLDWRUUHSDLU 3RWWHU\PDNLQJ /HDGVPHOWLQJ :HOGLQJ 0DNLQJILVKLQJZHLJKWV R R R R R No +RXVHFRQVWUXFWLRQRUUHSDLU %DWWHU\PDQXIDFWXUHRUUHSDLU %XUQLQJOHDGSDLQWHGZRRG $XWRPRWLYHUHSDLUVKRSRUMXQN\DUG *RLQJWRDILULQJUDQJHRUUHORDGLQJEXOOHWV R R R R R &KHPLFDOSUHSDUDWLRQ 9DOYHDQGSLSHILWWLQJV %UDVVFRSSHUIRXQGU\ 5HILQLVKLQJIXUQLWXUH 2WKHU Sources of lead in food and remedies? R R R R ,PSRUWHGRUJOD]HGSRWWHU\VXFKDVD0H[LFDQEHDQSRW ,PSRUWHGFDQG\OLNH&KDFD&KDFDHVSHFLDOO\IURP0H[LFR 1XWULWLRQDOSLOOVRWKHUWKDQYLWDPLQV 2WKHU R )RRGVFDQQHGRUSDFNDJHGRXWVLGHWKH86 R 5HPHGLHVVXFKDVJUHWDD]DUFyQDODUFyQDONRKO EDOLJROLFRUDOJKDVDUGOLJDSD\ORRDKUXHGD Cuestionario de Padre Sí No lo se No 1R¢9LYHVXKLMRDRYLVLWDXQDFDVDFHQWURGHJXDUGHUtDXRWURHGLILFLRFRQVWUXLGDDQWHVGH" 2R¢9LYHVXKLMRDRYLVLWDXQDFDVDFHQWURGHJXDUGHUtDXRWURHGLILFLRTXHHVWiVLHQGRSLQWDGD UHPRGHODGDRHQODTXHHVWiQSHODQGRROLMDQGRODSLQWXUD" 3R¢6XKLMRDFRPHRPDVWLFDFRVDVTXHQRVRQFRPLGDFRPRSHGD]RVGHSLQWXUDRWLHUUD" 4R¢7LHQHQSDULHQWHVRFRPSDxHURVGHVXKLMRDTXHWLHQHQRWXYLHURQDOWRVQLYHOHVGHSORPRHQODVDQJUH" 5R¢(VVXKLMRUHFLpQUHIXJLDGRRDGRSWDGRGHOH[WUDQMHUR" 6R¢+DVLGRH[SXHVWRVXKLMRDDFXDOTXLHUGHORVVLJXLHQWHV"VL6ÌPDUTXHWRGRVTXHDSOLTXHQ Contaminación de un padre, pariente, o amigo con trabajos o pasatiempos como estas? R R R R R 5HSDUDFLyQGHUDGLDGRUHV )DEULFDFLyQGHFHUiPLFD ,QGXVWULDGHOSORPR 6ROGDGXUD )DEULFDFLyQGHSHVDVSDUDSHVFDU R R R R R &RQVWUXFLyQRUHSDUDFLyQGHFDVDV )DEULFDFLyQRUHSDUDFLyQGHEDWHUtDV 4XHPDGHPDGHUDSLQWDGDFRQSORPR 7DOOHUPHFiQLFRSDUDDXWRVRORWHGHFKDWDUUD ,UDXQFDPSRGHWLURRUHFDUJDUEDODV Si “sí” o “no lo se” Le haga al niño una prueba de plomo en el sangre R 3UHSDUDFLyQGHTXtPLFRV R 3DUWHVVXHOWDVSDUDWXERVGH FDxHUtDV\YiOYXODV R )XQGLFLyQ GHODWyQFREUH R 7HUPLQDGRGHPXHEOHV R 2WURV Fuentes de plomo en comidas y remedios? R R R R R R 3URGXFWRVGHFHUiPLFDLPSRUWDGDRFRQUHFXEULPLHQWRGHEDUQL]FRPRXQDROODSDUDIULMROHVGH0p[LFR 3URGXFWRVHQODWDGRVRHPSDFDGRVIXHUDGHORV(VWDGRV8QLGRV 'XOFHVLPSRUWDGRVFRPR&KDFD&KDFDHVSHFLDOPHQWHGH0p[LFR 5HPHGLRVWUDGLFLRQDOHVFRPRJUHWDD]DUFyQDODUFyQDONRKOEDOLJROLFRUDOJKDVDUGOLJDSD\ORRDKUXHGD 3tOGRUDVDOLPHQWLFLDVFRQH[FHSFLyQGHODVYLWDPLQDV 2WURV Fax completed form to 512-458-7699, or mail to the address below. 7H[DV&KLOGKRRG/HDG3RLVRQLQJ3UHYHQWLRQ3URJUDP 32%2;$XVWLQ7;ZZZGVKVVWDWHW[XVOHDG 3DJHRI 5HYLVHG CH-335 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 A.5 Tuberculosis Screening and Education Tool This screening tool for tuberculosis (TB) exposure risk is to be used annually to determine the need for tuberculin skin testing. In areas of high TB prevalence, the screening tool need not be done at visits for which tuberculin skin testing is required: 1 year of age, once between 4 years of age and 6 years of age, and once between 11 years of age and 17 years of age. The questions in this screening tool are intended as a minimum screen. Follow-up questions may be necessary to clarify hesitant or ambiguous responses. Questions specific to TB exposure risks in the client’s community may need to be added. • If all the answers are unqualified negatives, the client is considered at low risk for exposure to TB and will not need tuberculin skin testing. • If the answer to any question is “Yes” or “I don’t know,” the client should be tuberculin skin tested. • In the case of the client for whom an answer in the past of “Yes” or “I don’t know” prompted a skin test, which was negative, the skin test may not have to be repeated annually. • The decision to administer a skin test must be made by the medical provider based upon an assessment of the possibility of exposure. A negative tuberculin skin test never excludes tuberculosis infection or active disease. • Bacillus of Calmette and Guérin (BCG) vaccinated clients should also have the screening tool administered annually. Previous BCG vaccination is not a contraindication to tuberculin skin testing. Positive tuberculin skin tests in BCG vaccinated children are interpreted using the same guidelines used for non-BCG vaccinated children. • clients who have had a positive TB skin test in the past (whether treated or not), should be reevaluated at least annually by a physician for signs and symptoms of TB. Care of clients who are newly discovered to be tuberculin skin test positive includes: • An evaluation for signs and symptoms of TB. • A chest X-ray to rule out active disease. • Oral medications to prevent progression to active disease or multi-drug therapy if active disease is present. • Referral for consultation by a pediatric TB specialist is recommended if active disease is present. • A report to the local health authority for investigation to find the source of the infection. Feel free to photocopy the screening and education tool from this publication. CH-336 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.59 TB Questionnaire TB Questionnaire Name of Child____________________________________________________________Date of Birth ________________ Organization administering questionnaire______________________________________ Date_______________________ Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by the child. Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration, loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats. A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI). Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis. The skin test is not a vaccination against TB. We need your help to find out if your child has been exposed to tuberculosis. Place a mark in the appropriate box: Yes No Don't Know TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two weeks), or coughing up blood. As far as you know: has your child been around anyone with any of these symptoms or problems? or has your child had any of these symptoms or problems? or has your child been around anyone sick with TB? Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia? Has your child traveled in the past year to Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks? If so, specify which country/countries?______________________________________ To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the United States from another country? Has your child been tested for TB? Has your child ever had a positive TB skin test? Yes___ (if yes, specify date ____/____) Yes___ (if yes, specify date ____/____) No___ No___ For school/healthcare provider use only *************************************************************************************************** PPD administered Yes___ No___ If yes, Date administered _____/_____/______ Date read ______/______/_______ Result of PPD test __________ mm response Type of service provider (i.e. school, Health Steps, other clinics) _______________________________________________ PPD provider __________________________________________ signature Provider phone number ______________________________________ printed name ___________________________________ City ________________________________________________ County ________________________________________ If positive, referral to healthcare provider Yes___ No___ If yes, name of provider _______________________________________________________________________________ EF12-11494 TB Questionnaire for Children (Rev. 08/04) CH-337 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.60 Cuestionario Para la Detección de Tuberculosis Cuestionario de Tuberculosis Nombre del niño o niña _____________________________________________________________________________________ Organización ____________________________________________________________ Fecha ___________________________ La Tuberculosis (TB) es una enfermedad causada por gérmenes de TB y en la mayoriá de los casos es trasmitida por una persona adulta con tuberculosis pulmonar activa. Se transmite a otra persona por la tos y por el estornudo al expelir gérmenes de TB al aire que pueden ser respirados por los niños. Los adultos que tienen la enfermedad activa casi siempre tienen varios de los siguientes síntomas: tos con duración de más de dos semanas, pérdida de apetito, pérdida de peso de diez libras o más en un período corto de tiempo, fiebre, escalofríos y sudores nocturnos. Una persona puede tener gérmenes de TB en su cuerpo pero no tener la enfermedad activa. Esto se llama infección latente de TB (o LTBI por su sigla en inglés). La TB es prevenible y curable. La prueba tuberculínica, también llamada PPD o prueba de Mantoux, se utiliza para saber si su niño o niña ha sido infectado/a con el germen de TB. No se recomienda ninguna vacuna para prevenir la tuberculosis. La prueba tuberculínica no es una vacuna contra la tuberculosis. Necesitamos de su ayuda para saber si su niño/niña ha sido expuesto/a a la tuberculosis. Sí No No se sabe La tuberculosis puede causar fiebre de larga duración, pérdida de peso inexplicable, tos severa (con más de dos semanas de duración), o tos con sangre. ¿Es de su conocimiento si: su niño o niña ha estado cerca de algún adulto con esos síntomas o problemas? su niño o niña ha tenido algunos de estos síntomas o problemas? su niño o niña ha estado cerca de alguna persona enferma de tuberculosis? ¿Su niño o niña nació en México en o cualquier otro país de América Latina, el Caribe, Africa, Europa Oriental o Asia? ¿Su niño o niña viajó a México o a cualquier otro país de América Latina, el Caribe, Africa, Europa Oriental o Asia durante el último año por más de 3 semanas? Si su respuesta es positiva, favor de especificar a qué país o países. ¿Es de su conocimiento, si su niño o niña pasó un tiempo (más de 3 semanas) con alguna persona que es o ha sido usuario de droga intravenosa (IV), infectado por VIH, en la prisión, o haya llegado recientemente a los Estados Unidos? ¿A su niño o niña se le ha realizado la prueba tuberculínica recientemente? ¿Su niño o niña alguna vez tuvo reacción positiva a la tuberculina? Sí___ (si sí, especifique la fecha ____/____) No___ Sí___ (si sí, especifique la fecha ____/____) No___ Solamente para uso de la escuela o del proveedor de servicios médicos ****************************************************************************************************** ¿Se administró PPD? Sí___ No___ Si sí, Fecha en que fue administrada_____/_____/_____ Fecha de lectura _____/______/_____ Resultado de la prueba_____ mm Tipo de proveedor de servicio (ej.: escuela, Health Steps, otras clínicas) ____________________________________________ Administrador de PPD ___________________________________________ firma _____________________________________ nombre en letra de molde (imprenta) Número de teléfono del administrador de PPD ___________________________________ Ciudad________________________________________________ Condado_______________________________________ Si resultó positivo, ¿se refirió al proveedor de servicios de salud? Sí___ No___ Si sí, nombre del proveedor (médico o clínica, etc.) ____________________________________________________________ EF12-11494A (Rev. 08/04) CH-338 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.61 How to Determine TB Risk Risk of potential tuberculosis exposure as revealed by questionnaire YES NO Past TB skin test No skin test NO YES Skin test (+)Positive No skin test Symptoms of TB disease YES (-) Negative Has risk occurred since last negative skin test YES (+)Positive (-) Negative No further action NO Clinical exam* NO Skin test No skin test Clinical exam* Therapy completed YES (+)Positive (-) Negative No further action NO Clinical exam* No further action Clinical exam* * Clinical exam includes: medical/social history physician exam chest x-ray Consult physician/TB health experts about need for: bacteriology treatment CH-339 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.62 PPD Agreement for Texas Health Steps Providers Infectious Disease Control Unit PPD Agreement for Texas Health Steps Providers Please Print Facility Name: ___________________________________________________________________________________ Address: ______________________________________(City, State)___________________(Zip)____________ Provider Name: __________________________________________ Provider Title: ____________________________ Contact Name: __________________________________________ Contact Title: ____________________________ Contact Phone: __________________________________________ Contact Fax: ____________________________ In order to receive State-supplied PPD at no cost to me, I, on behalf of myself and any and all practitioners associated with this medical office, group practice, health department, community/migrant/rural health clinic, or other organization of which I am the physician in charge or equivalent, agree to the following: 1. I agree to provide/arrange training for all personnel in administering, reading, and recording the TB skin test results. I agree to instruct all patients that the TB skin test is a two (2)-part test and they must return in 48 to 72 hours for their test to be read by trained personnel so the test result can be documented. I agree to have all results documented in millimeters and a negative test will be recorded as 0 mm not negative. I agree to supply written documentation of the training to administer TB skin testing, reading and recording upon request of the health department issuing the PPD. 2. I agree to do the screening for TB risk factors on each patient and ONLY place the TB skin test on those patients that have a TB risk factor or have some other medical necessity that is documented in their chart or are entering foster care. 3. I agree to submit TB-400 forms or refer clients to the health department for medical evaluation or additional follow-up when they have latent TB infection (positive skin test result and a negative chest x-ray). 4. In accordance with the Texas Administrative Code, Title 25, Part 1, Chapter 97, Subchapter A, I shall report to the local health authority any known or suspected case of TB within one working day and any new diagnosis of latent TB infection within one week. 5. I agree to submit the Monthly Tuberculin Skin Testing Form (EF12-12168). This form will be sent at the first of each month showing our TB testing numbers for the previous month. I agree to monitor my stock levels so that emergency orders will be kept to a minimum. 6. As a private clinic or health care facility, I agree to use this PPD only for TB screening of children as part of a Texas Health Steps medical check-up and to identify and document TB risk factors before placing the PPD. 7. Either the State or I may terminate this agreement at any time. My failure or the failure of any others outlined above to comply with these requirements will be grounds for the State to terminate this agreement. ________________________________________________ Provider Signature Sign and Return to: ______________________________ Date A copy of this agreement will be returned to you. ________________________________________________ Health Department Representative Signature ______________________________ Date EF12-12105 PPD Agreement (Rev. 6/05) CH-340 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. CHILDREN’S SERVICES HANDBOOK CH.63 TVFC Patient Eligibility Screening Record CLINIC USE ONLY: TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC) PATIENT ELIGIBILITY SCREENING RECORD TVFC Eligible: Yes No Purpose: To determine eligibility and the source of funds for the Texas Department of State Health Services to be reimbursed for vaccines. A record must be kept in the office of the health-care provider that reflects the status of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children Program. The record may be completed by the parent, guardian, or individual of record. This same record may be used for all subsequent visits as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines. Date of Screening: Child’s Name: Last Name First Name MI Child’s Date of Birth: mm/dd/yy Parent/Guardian/Individual of Record: Last Name First Name MI Provider’s/Clinic’s Name: Please select one of the following categories (check the first category that applies, check only one) to determine if the child is TVFC eligible: (a) is enrolled in Medicaid, or (b) does not have health insurance, or (c) is an American Indian, or (d) is an Alaskan Native, or (e) is a patient who receives benefits from the Children’s Health Insurance Plan (CHIP), or (f) is underinsured (has health insurance that Does Not pay for vaccines, has a co-pay or deductible the family cannot meet, or has insurance that provides limited wellness or prevention coverage), or (g) is a patient who is served by any type of public health clinic and does not meet any of the above criteria (a-f), or (h) has private insurance, or is paying for services. Signature: Date: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004) Texas Department of State Health Services Immunization Branch CH-341 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock No. C-10 Revised 02/09 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.64 TVFC Patient Eligibility Screening Record (Spanish) TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC) [EL PROGRAMA DE VACUNAS PARA LOS NIÑOS DE TEXAS, TVFC, por sus siglas en inglés] ARCHIVO QUE DETERMINA LA ELEGIBILIDAD DEL PACIENTE uso de la clínica solamente: (CLINIC USE ONLY:) TVFC Eligible: Yes No Propósito: El determinar la elegibilidad y el origen de los fondos para rembolsar al Texas Department of State Health Services (Departamento Estatal de Servicios de Salud de Texas) por las vacunas. Un archivo debe guardarse en la oficina del proveedor de atención médica, el cual refleja el estatus de todos los niños de 18 años de edad o menores quienes reciben inmunizaciones a través del Programa de Vacunas Para los Niños de Texas. El formulario puede ser llenado por el padre, la madre, el tutor legal o el individuo del registro. Este mismo formulario puede utilizarse para todas las visitas subsiguientes con tal de que el estatus de elegibilidad del niño no haya cambiado. Aunque la verificación de las respuestas no es requerida, es necesario retener éste, o un archivo similar, para cada niño que reciba vacunas. Fecha de determinación: Nombre del niño: Apellido Primer nombre Inicial del segundo nombre Primer nombre Inicial del segundo nombre Fecha de nacimiento del niño: (mes/día/año) Padre / Madre / Tutor legal / Individuo del registro: Apellido Nombre del proveedor / nombre de la clínica: Sírvase seleccionar una de las categorías siguientes (marque la primera categoría que se aplica; marque solamente una) para determinar si el niño cumple los requisitos para recibir vacunas del TVFC: (a) está inscrito en Medicaid, o (b) no tiene seguro médico, o (c) es Indio-Americano, o (d) es nativo de Alaska, o (e) es un paciente que recibe beneficios del Children’s Health Insurance Plan (Plan de seguro médico para niños, CHIP, por sus siglas en inglés), o (f) no tiene seguro médico suficiente (tiene seguro médico que NO paga por las vacunas; tiene un copago o un deducible que la familia no puede pagar; o tiene un seguro que proporciona una cobertura limitada para el bienestar o la prevención), o (g) es un paciente que recibe servicios de cualquier clínica de salud pública y no reúne ninguno de los criterios indicados anteriormente (a-f), o (h) tiene seguro privado o está pagando por servicios. Firma: Fecha: Con pocas excepciones, usted tiene el derecho a pedir y ser informado(a) sobre la información que el Estado de Texas reúne sobre usted. Usted tiene el derecho a recibir y examinar la información al pedirla. Usted también tiene el derecho a pedirle a la agencia estatal que corrija cualquier información que se determina ser incorrecta. Vaya a http://www.dshs.state.tx.us para más información acerca de la Notificación sobre la Privacidad. (Referencia: Government Code, Section 552.021, 552.023, 559.003 y 559.004) Texas Department of State Health Services Immunization Branch CH-342 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock No. C-10 Revised 02/09 CHILDREN’S SERVICES HANDBOOK CH.65 TVFC Provider Enrollment (3 Pages) TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC): PROVIDER ENROLLMENT Initial enrollment* Re-enrollment Provider PIN Number __ __ __ __ __ __ *Contact the Health Services Region (HSR) in your area to obtain PIN Name of Facility, Practice, or Clinic: Provider Name (M.D., D.O., N.P., P.A., or C.N.M.*): (Last Name) (First Name) (MI) (Title) Contact: (Last Name) (First Name) (MI) (Title) Mailing Address: (P.O. Box or Street Address) (City) (Zip) Address for Vaccine Delivery: (Street Address and Suite Number) Telephone Number: ( ) (City) Fax Number: ( (County) (Zip) ) E-mail Address: In order to participate in the Texas Vaccines for Children Program and/or to receive federally- and state-supplied vaccines provided to me at no cost, I, on behalf of myself and any and all practitioners associated with this medical office, group practice, health department, community/migrant/rural health clinic, or other organization, agree to the following: 1) This office/facility will screen patients for VFC eligibility at all immunization encounters, and administer VFC-purchased vaccine only to children 18 years of age or younger who meet one or more of the following criteria: (1) Is an American Indian or Alaska Native; (2) is enrolled in Medicaid; (3) has no health insurance; (4) is underinsured: children who have commercial (private) health insurance but the coverage does not include vaccines, children whose insurance covers only selected vaccines (VFC- eligible for non-covered vaccines only), children whose insurance caps vaccine coverage at a certain amount (once that coverage amount is reached, these children are categorized as underinsured), or has insurance with a co-pay or deductible the family cannot meet, (5) is a patient who receives benefits from the Children’s Health Insurance Plan (CHIP); (6) is a patient who is served by any type of public health clinic and does not meet any of the above criteria. 2) This office/facility will maintain all records related to the VFC program, including parent/guardian/authorized representative’s responses on the Patient Eligibility Screening Form for at least three years. If requested, this office/facility will make such records available to the Texas Department of State Health Services (DSHS), the local health department/authority, or the U.S. Department of Health and Human Services. 3) This office/facility will comply with the appropriate vaccination schedule, dosage, and contraindications, as established by the Advisory Committee on Immunization Practices, unless (a) in making a medical judgment in accordance with accepted medical practice, this office/ facility deems such compliance to be medically inappropriate, or (b) the particular requirement is not in compliance with Texas Law, including laws relating to religious and medical exemptions. 4) This office/facility will provide Vaccine Information Statements (VIS) to the responsible adult, parent, or guardian and maintain records in accordance with the National Childhood Vaccine Injury Act which include reporting clinically significant adverse events to the Vaccine Adverse Event Reporting System (VAERS). Signatures are required for informed consent. (The Texas Addendum portion of the VIS may be used to document informed consent.) 5) This office/facility will not charge for vaccines supplied by DSHS and administered to a child who is eligible for the TVFC. 6) This office/facility may charge a vaccine administration fee to non-Medicaid VFC-eligible patients not to exceed $14.85. Medicaid patients cannot be charged for the vaccine, administration of vaccine, or an office visit associated with Medicaid services. For Medicaid patients, this office/facility agrees to accept the reimbursement for immunization administration set by the state Medicaid agency or the contracted Medicaid health plans. 7) This office/facility will not deny administration of a TVFC vaccine to a child because of the inability of the child’s parent or guardian/individual of record to pay an administrative fee. 8) This office/facility will comply with the State’s requirements for ordering vaccine and other requirements as described by DSHS, and operate within the VFC program in a manner intended to avoid fraud and abuse. 9) This office/facility or the State may terminate this agreement at any time for failure to comply with these requirements. If the agreement is terminated for any reason this office/facility agrees to properly return any unused vaccine. 10) This office/facility will allow DSHS (or its contractors) to conduct on-site visits as required by VFC regulations. (Signature*) (Date) (Print Name and Title) * A licensed Medical Doctor, Doctor of Osteopathy, Nurse Practitioner, Physician Assistant, or a Certified Nurse Midwife must sign the TVFC Enrollment form. Texas Department of State Health Services Immunization Branch CH-343 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock Number E6-102 Revised 12/2007 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 TEXAS VACCINES FOR CHILDREN PROGRAM PROVIDER PROFILE FOR PIN ___ ___ ___ ___ ___ ___ Is your facility a Federally Qualified Health Center, Migrant Health Clinic, or Rural Health Clinic? (Circle one) YES NO Type of Clinic: (check one) Public Health Department/District Public Hospital Other Public Clinic Private Hospital Private Practice (Individual or Group) Other Private Clinic PATIENT PROFILE: Please enter the number of children for each of the following categories and by age group who will be vaccinated at your clinic in the next 12-month period. NUMBER OF CHILDREN IN EACH CATEGORY < 1 year old 1 - 6 years 7 - 18 years Total Enrolled in Medicaid. Uninsured. (Note: Children enrolled in Health Maintenance Organizations are considered insured) American Indians. Alaskan Natives. Underinsured. (Has health insurance that Does Not pay for vaccines, has a co-pay or deductible the family cannot meet, or has insurance that provides limited wellness or prevention coverage.) (For Public Health Clinic Use ONLY) Children who do not meet any of the above criteria, but still receive vaccinations at public health clinics. Children who receive benefits from the Children’s Health Insurance Plan (CHIP). Children who are vaccinated in your practice, but are NOT TVFC-eligible. TOTAL PATIENTS: (Add columns) TEXAS VACCINES FOR CHILDREN PROGRAM PROVIDER LIST Please list all individuals within the practice who will be administering TVFC supplied vaccine. Last Name (List provider who signed Provider Enrollment Formfirst) First Name Middle Title (M.D., D.O., National Initial N.P., P.A., R.N., Provider L.V.N., M.A.) Identification Medical License Number Texas Department of State Health Services Immunization Branch CH-344 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Specialty (Family Medicine, Pediatrics, etc.) Stock Number E6-102 Revised 12/2007 ccc CHILDREN’S SERVICES HANDBOOK TEXAS VACCINES FOR CHILDREN PROGRAM PROVIDER LIST-ADDENDUM FOR PIN ___ ___ ___ ___ ___ ___ Please list all individuals within the practice who will be administering TVFC supplied vaccine. Last Name (List provider who signed Provider Enrollment Form first) First Name Middle Title (M.D., National Initial D.O., N.P., P.A., Provider R.N., L.V.N., M.A.) Identification Medical License Number Texas Department of State Health Services Immunization Branch CH-345 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Specialty (Family Medicine, Pediatrics, etc.) Stock Number E6-102 Revised 12/2007 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 CH.66 TVFC Questions and Answers (3 Pages) T e x a s Questions and Answers Texas Vaccines For Children Program (TVFC) Question 1: What is the TVFC? V a c c i n e s Answer: F o r Answer: C h i l d r e n P r o g r a m This is our version of the Federal Vaccines For Children (VFC) Program. The TVFC was initiated by the passage of the Omnibus Budget Reconciliation Act of 1993. This legislation guaranteed vaccines would be available at no cost to providers, in order to immunize children (birth - 18 years of age) who meet the eligibility requirements. Why Enroll? Question 2: Why should a health care provider enroll in the TVFC? x x x You can get free vaccine for your eligible patients. You will not need to refer patients to public clinics for vaccines. You can provide vaccinations to your patients as part of a comprehensive care package; this will enhance the opportunity for patients to find a medical home. Patients Served Question 3: Once enrolled, are providers required to immunize children who are not their patients? Answer: No, you control whom you see in your practice. Children Who Qualify Question 4: Which children qualify for free vaccines? Answer: All children (birth - 18 years of age) are eligible for free vaccine, except: x Children with insurance that pays for immunization services, and x Children whose parents or guardians are able to pay the copay or deductibles for immunization services. Texas Department of State Health Services Immunization Branch Page 1 CH-346 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock No. 11-11221 Revised 01/2008 CHILDREN’S SERVICES HANDBOOK T e x a s V a c c i n e s F o r C h i l d r e n P r o g r a m Questions and Answers Children’s Health Insurance Program (CHIP) Enrollment Question 5: Are children who are enrolled in CHIP eligible? Answer: Yes, through special arrangement CHIP children are also eligible. Medicaid Enrollment Question 6: To participate in TVFC, must providers enroll as a Texas Medicaid Provider? Answer: No, however, if you are enrolled in the Texas Medicaid Program, you must enroll in TVFC in order to receive free vaccine. Question 7: Will the Texas Medicaid Program reimburse private providers for vaccines administered to Medicaid patients? Answer: The Texas Medicaid Program will not reimburse providers for the cost of the vaccine. However, the Texas Medicaid Program will reimburse providers for the administration of the vaccine. Vaccine Related Fees Question 8: Why are there fee caps on what providers can charge for administering vaccine? Answer: Federal Legislation requires fee caps for administration on a statewide basis that balance the provider’s financial need and the patient’s ability to pay. Question 9: Will TVFC reimburse an administration fee for non-Medicaid, TVFC eligible children? Answer: No, for non-Medicaid TVFC eligible children, providers may charge a maximum of $14.85 per vaccine directly to the patient; administration fees may not exceed this amount. (Combination vaccines such as DTaP are considered one vaccine.) Texas Department of State Health Services Immunization Branch Page 2 CH-347 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock No. 11-11221 Revised 01/2008 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 T e x a s V a c c i n e s F o r C h i l d r e n P r o g r a m Questions and Answers Question 10: Will providers be required to increase the amount of vaccine information materials they provide to parents because of the TVFC? Answer: No, materials required of all providers through the National Childhood Vaccine Injury Act are sufficient. Eligibility Status Question 11: Must providers screen patients for eligibility status each time they come for a vaccination visit? Answer: Yes, providers must screen patients for eligibility status each time they come for a vaccination visit. However, a new eligibility form does not need to be completed unless the patient’s eligibility status has changed. Question 12: How are providers expected to verify responses for TVFC eligibility? Answer: Providers are not expected to do anything more than ask the patient what the child’s eligibility status is and then record the response. TVFC provides a Patient Eligibility Screening Form that can be used for this. Question 13: Why must providers complete a Provider Profile describing patients by eligibility category? Answer: This information allows the Texas Department of State Health Services to determine how the cost of vaccine will be divided among state and federal funds. Each year, you may find your profile information has changed. The Provider Profile must be updated annually, in accordance with Federal requirements. Texas Department of State Health Services Page 3 CH-348 CPT ONLY - COPYRIGHT 2010 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. Stock No. 11-11221